Lisa Day

25th April 2016 

Coroner ME Hassell  
Senior Coroner  
Inner North London  
St Pancras Coroner’s Court  
Camley Street  
London N1C 4PP 

London Central & West 
Unscheduled Care Collaborative 

St. Charles Centre for Health & Wellbeing 
Exmoor Street 
London 
W10 6DZ 

Tel: 0208 962 7713 
Fax: 0208 962 4401 

Response to HM coroner in respect of regulation 28 (PFD report) 

Dear Ms Hassell 

Regulation 28: Prevention of Future Deaths report  
Lisa Margaret DAY (died 12.09.15) 

This  response,  on  behalf  of  London  Central  and  West  Unscheduled  Care  Collaborative 
('LCW  UCC')  in  respect  of  the  above,  will  address  the  following  concerns  put  to  the 
organisation in the PFD, namely: 

1 a)   When  Ms  Day’s  friend  rang  the  111  service  on  her  behalf,  the  possibility  of 
conveying  her  to  hospital  by  means  other  than  an  ambulance  was  discussed  with 
her and she declined.  

However,  it  was  not  discussed  with  her  friend  who  made  the  call.  He  would  have 
been  much  better  placed  to  organise  this  and,  if  he  had,  it  would  probably  have 
resulted in life saving hospital treatment.  

b)  

2.  

The  potentially  very  grave  consequences  of  a  vomiting  illness  in  a  person  with 
diabetes were not explained to him.  

I heard at inquest that the 111 and 999 services have begun a process to promote 
more  effective  communication  of  111  concerns  to  the  London  Ambulance  Service 
('LAS') in situations like this. It seems that this would be of great benefit to patients.  

Local response 

LCW  UCC  as  a  single  provider  of  111  services  under  licence  have  addressed  these 
concerns  in  conjunction  with  the  Pan  London  Integrated  Urgent  Care  Group  as  any 
recommendation  arising  requires  consideration  for  its  impact  across  111  providers  as  a 
system wide change to current practice. 

  An NHS Commissioned Organisation 
Mutual Society Registration:  London Central & West Unscheduled Care Collaborative Ltd 
Register No 29910R - Registered Office as above 

Chief Executive - Tonia Culpin 
Interim Medical Director – Dr Simon Douglass 

 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 Pan London Integrated Urgent care Group response 

Role of group and context of response 

LCW UCC is a licensed provider of 111 services and as such is required to comply with 
the  NHS  Pathways  end  user  license.  Any  system-wide  changes  to  111  practice  or 
systems  including  changes  to  standard  practice,  policy  or  training  are  therefore  not 
within  individual  providers  remit  to  change  without  the  approval  of  the  appropriate 
authority. 

In  response  to  this  regulation  28  report  issued  to  LCW  UCC,  one  of  the  NHS  111 
London  providers,  the  response  and  recommendations  arising  have  been  considered 
and  endorsed  by  the  Pan  London  Urgent  Care  Group  and  therefore  represents  a 
consensus  view  of  its  membership  comprising  of  providers,  commissioners  and 
representatives  from  Healthy  London  Partnership  and  the  National  111  team  at  NHS 
England. 

The Pan- London Integrated urgent care group met on the 15th March and the findings of 
the inquest touching the death of Ms Day  were discussed.  The issues discussed  were 
specifically  a  review  of  the  contact  with  London  Ambulance  service  and  111  and  the 
concerns put in this regulation 28 report further to the inquest. 

Discussion and conclusion of the Pan London group  

1.  a) Alternate means of conveyance to hospital 

Since September 2014, if an ambulance disposition is returned on the 111 system, other 
than  a  red  one  or  two  category  requiring  an  8  minute  emergency  response,  NHS 
England  has  required  that  all  111  service  providers  undertake  an  enhanced  clinical 
assessment by a NHS pathways trained clinician. This is usually either an experienced 
Paramedic  or  registered  nurse  who  determines  whether  an  ambulance  is  required  or 
whether there is a safe alternative that can be recommended.  

Staff undertaking this role need to identify clinical situations where an alternative means 
of conveyance may not be safe- either due to the severity of the patient’s symptoms or 
where their circumstances do not allow an alternative to be a viable option.  

On  reviewing  the  assessment  carried  out  on  the  severity  of  Ms  Day’s  symptoms,  the 
decision  to  dispatch  a  30  minute  ambulance  was  deemed  appropriate  and  accorded 
with the NHS Pathways assessment processes.  

At the time of the call, LAS reported a particularly high level of demand so the clinician 
who  undertook 
the 
ambulance service directly and did pass on her specific concerns re Ms Day’s need for 
an ambulance transfer for emergency treatment.  

the  assessment  and  dispatched 

the  ambulance  contacted 

Whilst  the  clinician  had  asked  Ms  Day  about  alternative  means  of  getting  to  hospital 
which  she  declined,  instead  responding  that  she  required  an  ambulance,  this  was  not 
further discussed with Ms Day’s friend who was making the call on her behalf. 

  An NHS Commissioned Organisation 
Mutual Society Registration:  London Central & West Unscheduled Care Collaborative Ltd 
Register No 29910R - Registered Office as above 

Chief Executive - Tonia Culpin 
Interim Medical Director – Dr Simon Douglass 

 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 It is acknowledged that this alternative means of conveyance if undertaken in Ms Day’s 
case  may  have  resulted  in  life  saving  hospital  treatment  and  as  a  result  the  group 
representing  all  London  111  providers  have  agreed  the  following  amendment  to  the 
memorandum  of  understanding  in  place  between  the  providers  and  the  London 
Ambulance Service: 

All  London  111  providers  will  at  times  of  likely  significant  delay  defined  by  London 
Ambulance Service as “Surge Purple” status or above will expect their clinicians carrying 
out  assessments  resulting  in  an  ambulance  emergency  treatment  and  transfer 
disposition  (requesting  a  30  minutes  response),  to  clearly  notify  the  patient  and  the 
person calling on their behalf (if any) that there is likely to be a significant delay and to 
consider whether they would prefer to convey the patient to hospital themselves if they 
have the means to do so. 

The risks of self transfer should be explained to the patient and the caller (if different). 
The decision to use alternative means of transport is that of the patient. Clinicians are to 
inform patients and callers to contact LAS for updates on the estimated time of arrival of 
the ambulance should they need to. 

The clinicians in these circumstances are to reiterate the worsening instructions given to 
the patient and person calling on the patient's behalf. 

b) Vomiting in a person with diabetes  

The 111 clinician did not offer specific information to Ms Day’s friend who was involved 
in the call process in relation to the significance of her symptoms of vomiting in type 1 
diabetes. The clinician did give the recommended “worsening instructions”, which must 
accompany any 111 call for the process to be deemed compliant.  

Worsening instructions within NHS pathways are standardised and in normal operating 
conditions present on screen for the operator as “scripts” to select those that apply and 
read back to the caller.  

Additional  scripting  of  condition  specific  additional  information  specifically  in  relation  to 
type  1  diabetes  has  been  raised  as  a  result  of  this  concern  with  the  National  NHS 
Pathways team for their consideration and response as a result. 

2. System wide changes implemented since inquest 

The process whereby a direct call to the ambulance service to pass on specific concerns by 
the clinician dispatching the 30 minute ambulance in this case, did not lead to any additional 
prioritisation within the ambulance service system of queuing.  

  An NHS Commissioned Organisation 
Mutual Society Registration:  London Central & West Unscheduled Care Collaborative Ltd 
Register No 29910R - Registered Office as above 

Chief Executive - Tonia Culpin 
Interim Medical Director – Dr Simon Douglass 

 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As  a  result  of  changes  to  internal  processes  in  LAS,  it  is  now  the  case  that  all  clinical 
information  of  this  nature  passed  over  by  phone  following  dispatch  of  a  green  category 
ambulance by 111 clinicians, will result in a priority being applied within the queue of LAS 
dispatch requests.  

This process went live for all London 111 providers and LAS on Monday 14th March 2016. 
Please see the detailed response from LAS. 

Yours sincerely 

Interim Medical Director 

  An NHS Commissioned Organisation 
Mutual Society Registration:  London Central & West Unscheduled Care Collaborative Ltd 
Register No 29910R - Registered Office as above 

Chief Executive - Tonia Culpin 
Interim Medical Director – Dr Simon Douglass

London Ambulance Service NHS

NHS Trust

Legal Services
Headquarters

220 Waterloo Road
London

Ms ME Hassell SE1 8SD

Senior Coroner

Inner North London

St Pancras Coroners Court
Camley Street

London

N1C 4PP

Tel: 0207 783 2001
Fax: 0207 783 2009

www.londonambulance.nhs.uk

Our Ref : INQ/10363/14
Date : 15thApril 2016

Dear Ms Hassell
Regulation 28: Report to Prevent Future Deaths- Lisa Margaret Day

Thank you of your Regulation 28 Report to Prevent Future Deaths dated 23 February 2016,
bringing to my attention and to the attention of Dr Tim Ladbrooke matters of concern:

1. When Ms Day's friend rang the 111 service on her behalf, the possibility of conveying her
to hospital by means other than an ambulance was discussed with her and she declined.

However, it was not discussed with her friend who made the call. He would have been
much better placed to organise this and, if he had, it would probably have resulted in life
saving hospital treatment.

The potentially very grave consequences of a vomiting illness in a person with diabetes
were not explained to him.

2. | heard at inquest that the 111 and 999 services have begun a process to promote more
effective communication of 111 concerns to the London Ambulance Service in situations
like this. It seems that this would be of great benefit to patients.

| understand that the first concern is a matter for the London Central and West Unscheduled
Care Collaborative and that Dr Ladbrooke will be responding.

With regard to the second concern, | am pleased to confirm that the London Ambulance
Service NHS Trust (LAS) have agreed a process with NHS 111 whereby clinicians from NHS
111 can alert the LAS Emergency Operations Control about the calls made to NHS 111
where there is a clinical concern. The electronic flagging system was introduced on 14 March
2016 following consultation with NHS 111. The “LAS Department of Education and
Development EOC Training Bulletin’, TB 02/16, dated 9 March 2016, and “111 Clinician
alerting process for patients where there is a clinical concern on a green ambulance referral”
v2.0 flowchart give examples of the patients whose presenting conditions are to be brought to
the attention of the LAS.

| have been advised by the LAS's Medical Director that whilst the new process is in its infancy
early indications are that the process of alerting the LAS about calls where there is a clinical
concern is working well.

As with other Regulation 28 Prevention of Future Deaths Reports this letter will be shared
with the National Ambulance Service Medical Directors’ Group (NASMeD) who advise the
Ambulance Association of Ambulance Chief Executives, and will also be shared with London
NHS 111 service providers.

| hope this reply is helpful in explaining the actions taken to address the matters of concern. In
closing | wish to offer my condolences to Ms Day's family.

Yours sincgrely,

[vo

Dr Fionna Moore
Chief Executive London Ambulance Service NHS Trust

Enclosures:

“LAS Department of Education and Development EOC Training Bulletin’, TB 02/16, dated 9
March 2016

111 Clinician alerting process for patients where there is a clinical concern on a green
ambulance referral” v2.0 flowchart